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LOW-ANGLE FIXATION IN FRACTURES OF THE FEMORAL NECK

R. S. GARDEN, PRESTON, ENGLAND

From the Orthopaedic Department, Preston Royal Infirmary

Fracture of the neck of the femur continues to be regarded as “ the unsolved fracture,”
but its claim to this distinction becomes increasingly insecure. Since the introduction of the
Smith-Petersen nail in 1931, unrelenting endeavours have been made to solve this problem,
and the literature reveals a wide variety of anatomical studies, statistical reviews, new methods
of reduction, fixation and bone-grafting techniques. The overall picture is one of some
confusion but two elementary points of universal agreement are seen to emerge : reduction
must be perfect; and fixation must be secure.
No one wi,ll deny the advantage of perfect reduction in the treatment of this or any
other fracture, but accurate reduction is not essential to union in fractures elsewhere.
Nevertheless, it is generally agreed that in fractures of the femoral neck full reduction is of
particular importance. In regard to fixation many new methods of treatment have been
devised. Wires, nails, multiple screws and lag bolts, combined bone-grafting procedures,
sliding and compression devices have all been described, each striving to achieve rigid
apposition ofthe fracture surfaces. As these newappliances and techniques have been introduced,
there has been an increasing tendency to rely on the safeguard of shaft fixation or to use a
more vertically placed fixation device.
Lowangle nailing was advocated in this country by Brittain in 1942, by Burns and Young
in 1944 and since then by many other surgeons. Dickson (1953) stated that “the Jewett-type
nail placed in low position so that it practically rests on the calcar femorale . . . apparently
increases the stability, and thus increases the likelihood of bone healing at the fracture site.”
KUntscher (1953) believed that the low-angle nail neutralised the muscular forces acting upon
the fracture and, since the nail entered the head obliquely, prevented rotation because the
head was pressed hard against the fracture site in the direction of the nail. He maintained
that low-angle nailing produced a fixation eight times stronger than that afforded by the
Smith-Petersen operation. Lastly, he stated that after this method of fixation the full weight of
the body could be supported. These are formidable claims.
The present inquiry was prompted by the assertion that low-angle nailing could sustain
the body weight. It was felt that confirmation of this claim would at the same time confirm
a singular advance in the management of femoral neck fractures, which are largely confined
to an age group in which degenerative processes, already far advanced, can easily be
accelerated by prolonged recumbency.

INTERNAL FIXATION

Internal fixation, whatever its form, must in some way respect the architecture of the
internal weight-bearing system in the proximal end of the femur if both weight bearing and
fixation of the fracture are to be achieved at one and the same time. It is suggested that the
lamellae of the internal weight-bearing system are a spiral continuation of the circumferential
lamellae in the femoral shaft, and the forces acting upon the proximal end of the femur are
primarily compressive and secondarily torsional in nature (Garden 1961). The medial lamellae
in the internal weight-bearing system are directed upwards at an angle of only 3 to 8 degrees
with the perpendicular and their rich endosteal lining forms the principal source of bone
repair after fractures of the femoral neck (Farkas, Wilson and Hayner 1948). Thus, internal
fixation need try to emulate only compressive and torsional elements in the proximal end of

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648 R. S. GARDEN

the femur, and its purpose should be to maintain the fragments of the medial arrangement
of lamellae in close approximation until healing is complete.
The question then arises whether any form of internal fixation can be expected to maintain
the fragments in apposition whilst sustaining body weight as well. Any metallic appliance
inserted almost horizontally across the fracture site traverses the thin cortical shell just below
the greater trochanter, and then lies in a cancellous bed within the trochanter and neck (Fig. 1).
It is difficult to obtain a secure hold on the distal fragment in this way, and the fixation appliance
is bound to cut out when weight bearing is undertaken. On the other hand, in oblique or
transverse fractures of the femoral shaft early walking may be safe after the insertion of a
rigidly positioned intramedullary nail. Body weight is then directed through the fracture

FIG. I
Frontal section of proximal end of the femur. Position of Smith-Petersen nail to show the
insecurity of its fixation in the distal fragment of a subcapital fracture where it pierces the
thin lateral cortex just below the greater trochanter, and where it lies in the soft medulla
of the neck.

fragments which the nail preserves in normal alignment whilst avoiding other than minimal
local strain. But the relatively simple mechanics of the femoral shaft do not apply to its
trochanteric area or neck. Here the problem is complicated, indeed created, by the angle
between the neck and shaft. Anatomically, this angle is in the region of 127 degrees, but
Nature does not recognise the whole of this angle in the transmission of weight-bearing
stresses. Backman (1957) considered that the direction of load in the proximal end of the femur
coincides with the principal direction of the medial trabecular stream in the internal weight-
bearing system, which lies at an angle of no more than 3 to 8 degrees with the perpendicular.
This is probably true for the anatomical specimen subjected to compression tests in the
laboratory, but, in the living femur which has to contend with both body weight and muscular
forces, a slightly less vertical direction should, theoretically, be more exact. The analogy of
the intramedullary nail in femoral shaft fractures is thus more applicable than at first appears.

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By this analogy, weight bearing in cervical fractures of the femur should be possible by the
use of a fixation appliance lying in a near-vertical position within the spiral of the neck,
and depending for its purchase upon compact rather than cancellous bone. By directing the
body weight through the structure best suited to sustain it, namely the actual bone of the
femoral head and neck, an appliance so placed should then maintain the fragments in alignment
whilst, at the same time, itself evading the direct strains of weight bearing.
The Smith-Petersen nail was designed to prevent rotation of the fragments in the long
axis of the neck, but such rotation is unlikely to occur, because the serrated fragments are
firmly apposed and the capital fragment is mobile. The deforming rotation in subcapital
fracture takes place in the more vertical mechanical axis of the femur as the affected limb
tends to roll outwards. The fragments at first
rotate in opposite directions like two cog-wheels
in mesh, but as the deformity increases the cogs
are disengaged or broken, as it were, and the
cervical fragment comes to lie in front of the
head. It is with this lateral rotation deformity
that internal fixation must contend, and it is
this force which causes displacement ofa horizon-
tally positioned nail lying in the soft cancellous
bone of the distal fragment.
Some protection from this tendency to slip
is afforded by shaft fixation with a combined
nail and plate. This combination, however,
continues to work at a distinct mechanical
disadvantage because support is provided at the
wrong end of the nail. Lateral rotation forces
acting on the point of the nail are transferred to
its base, and breaking, bending or twisting at the
junction of nail and plate is not unusual.
The unsatisfactory results of the Smith-
Petersen procedure are well illustrated by the
reluctance of many surgeons to depend upon the
trifin nail alone. Some have advocated a combined FIG. 2
bone-grafting procedure; some have insisted upon Subeapital fracture of the femur treated by
low-angle K#{252}ntscher nail showing rigid fixation
reduction in the deceptive valgus position; some
of the nail in the distal fragment where it pierces
have advised an intertrochanteric or wedge osteo- the strong lateral cortex well below the greater
trochanter, and where it lies against the calcar
tomy: and some-in despair-have resorted to
femorale and inferior buttress of the neck.
removal of the head and replacement by a pros-
thesis. King (1939), Patrick (1949) and others have combined a bone graft with the
Smith-Petersen pin, but it is noteworthy that their published radiographs show the pin in low
position to accommodate the graft above it. Godoy Moreira and Camargo (1957) have also
had recourse to the use of a bone graft which, likewise, has displaced their stud-bolt downwards
to a position of stability on the calcar femorale. Most workers in this field who have
improved their results have done so by ensuring that the two fragments are held in stable
contact whilst at the same time minimising the unnatural stresses of metal impinging upon bone.
It is now freely recognised that a nail or screw placed almost horizontally is mechanically
unsound, and that any form of appliance for internal fixation must be placed more vertically.
The low-angle nail which pierces the strong lateral femoral cortex well below the greater
trochanter and which then lies against the buttress of the calcar femorale obtains a rigid
two-point fixation in the distal fragment (Fig. 2). One method at least, therefore, can provide
an unyielding purchase in this fragment. Unfortunately, it is difficult to establish a similar

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650 R. S. GARDEN

hold on the proximal fragment. This is especially true in the subcapital fracture of the aged
where the femoral head is so degenerate and friable that internal fixation by any means at
present known is, at best, precarious.

SUBCAPITAL SEPARATION

High cervical fractures often follow the most trivial injury, and sometimes there is no injury
at all. It is often impossible to determine whether the fracture was the result or the cause of

FIG. 4 FIG. 5
FIGS. 3 TO 5
Serial radiographs to illustrate the successive stages in the development of a stress fracture of the femoral neck.
Figure 3-Initial radiograph. Figure 4-One month later. Figure 5-Eight days later.

a fall, and the resemblance of these injuries to pathological fractures is not easy to ignore.
Subcapital separation has been ascribed to degenerative changes in the blood vessels of the
marrow (Farkas et a!. 1948). If this subcapital separation is but the culmination of a natural
degenerative process and not the result of an injury, then the use of the term “fracture” in

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describing this condition would be misleading. The following considerations suggest, however,
that subcapital separation is not entirely a pathological process.
With advancing age the muscles that control the hip joint gradually lose their tone, and
therefore their ability to continue the mechanically difficult part which they play in the act
of walking. Balancing on one leg becomes progressively more uncertain, and this uncertainty
is increased by a decline in the acuity of the special senses. Consequently, the swinging gait
of youth and middle age gives way to the shuffling gait of the aged. In response to this
redistribution of the weight-bearing stresses, the head and neck of the femur presumably
undergo functional realignment of their weight-bearing systems. During the preliminary

FIG. 6 E.G. 7
Figure 6-STAGE I: iNCOMPLETE SUBCAPITAL FRACTURE. The abducted ‘ or’ impacted’ injury in which the
fracture of the inferior cortical buttress is greenstick in nature, and a minimal degree of lateral rotation of
the distal upon the proximal fragment creates the radiological illusion of impaction. The medial lamellae of
the internal weight-bearing system in the distal fragment lie in abduction as compared with those in the capital
fragment which, itself, is adducted. If unprotected, this fracture may at any time become complete.
Figure 7-STAGE II: COMPLETE SUBCAPITAL FRACTURE WITHOUT DISPLACEMENT. The inferior cortical buttress
has been broken, but no tilting of the capital fragment has taken place. As in the Stage I fracture, the closely
opposed fragments in this complete fracture may succumb to lateral rotation forces and show the classical
displacement of subcapital separation.”

process of softening which this must entail, a stress fracture may readily occur. This can
sometimes be observed radiologically as it takes place (Figs. 3 to 5), and it may well be that
many such incomplete fractures remain unrecognised and heal spontaneously.
The line of cleavage in this stress fracture starts at the upper cervico-capital junction
and gradually runs downwards until it meets the inferior cortical buttress of the neck. The
strains of weight bearing then devolve largely upon this buttress, which must itself share in
the remodelling process. So far this process has resulted in a gradual dissolution of continuity
in the internal weight-bearing system, but the final stage entails an actual fracture of the
weakened inferior cortex. A minor twist, an unguarded action, an uneven step or, it may be,
a normal step, shatters this cortex and subcapital separation is complete. The proximal
fragment is then a cone-shaped segment with radiographic evidence of recent fracture showing

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652 R. S. GARDEN

mainly at the tip of the cone where comminution is almost always to be found (Fig. 8).
Occasionally a greenstick fracture occurs and the so-called abduction or impacted fracture
then results (Fig. 6). It is not, of course, suggested that all subcapital fractures are of this
stress variety and follow trivial injury. It is presumed that in those caused by single definite
injuries there has been a true fracture through healthy bone.
Many patients with subcapital fractures show at first little shortening or lateral rotation
of the limb. Within a few hours or days, however, both shortening and rotation are found
to increase. The strong retinaculum of Weitbrecht in the posterior capsule is unlikely to be
torn in these injuries, but in the anatomical specimen this structure can readily be stripped

FIG. 8 FIG. 9
Figure 8-STAGE III: COMPLETE SUBCAPITAL FRACTURE WITH The two fragments
PARTIAL DISPLACEMENT. retain
their posterior retinacular
attachment, and crushing of the posterior cervical cortex has not yet taken place.
Lateral rotation of the distal fragment therefore tilts the capital fragment into abduction and medial rotation as
shown radiologically by the direction of the medial weight-bearing lamellae in the femoral head. If the tendency
for the limb to rotate laterally is not resisted by external or internal fixation, stripping of the retinacular attachments
and crushing of the thin posterior cervical cortex will allow the full displacement of Stage IV to occur.
Figure 9-STAGE 1V: COMPLETE SUBCAPITAL FRACTURE WITH FULL DISPLACEMENT. This stage is reached when
the retinacular hinge is detached from the posterior surface of the neck and collapse of the posterior cortical shell
has taken place. The fragments are then divorced from each other, and the capital fragment at once returns
to a more normal position in the acetabulum. Its medial weight-bearing lamellae are then seen radiologically
to lie in alignment with their fellows in the pelvis.

from the posterior aspect of the neck (Fig. 10). The tilting of the femoral head in medial
rotation and abduction which is so frequently seen in the fresh injury (Fig. 8), suggests that
the capital fragment at first retains its posterior attachment to the neck through this retinaculum.
The tendency for the limb to rotate laterally will then be resisted by the retinaculum which
under the strain will gradually separate from the posterior surface of the neck and allow
further deformity to occur. At the same time great pressure will be concentrated on the
pivot of the lateral rotation forces at the posterior aspect of the fracture line, with crushing
or splintering of the thin posterior cortical shell of the neck. Open reduction of these
fractures shows how tightly the fragments are apposed by the surrounding soft tissues,
and it is doubtful if full lateral rotation of the distal fragment is possible until at least some

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degree of posterior cortical collapse has taken place. When such displacement has occurred
the capital fragment is released from the deforming influence of the distal fragment and at
once returns to a more normal position in the acetabulum. Its medial trabeculae then lie in
alignment with their fellows in the pelvis (Fig. 9).

CLASSIFICATION

Fractures of the femoral neck were at first classified as intracapsular and extracapsular and
later distinguished as subcapital, mid-cervical, basal, intertrochanteric or pertrochanteric types.
The subcapital type was further subdivided into abduction, or impacted, and adduction, or

_Ij

FIG. 10
Subcapital fracture of the femur showing hinge effect of the retinaculum of
Weitbrecht in the posterior capsule. After Smith (1953).

varus fractures, but since the classic description by Linton (1949) of the true nature of these
fractures this method of subdivision has gradually been discarded in favour of the Pauwels
(1935) classification based upon the obliquity of the fracture line as shown in the antero-
posterior radiograph. The actual direction of this line, however, remains remarkably constant,
and only on rare occasions is a true variation in its obliquity to be found. Subcapital fractures
tend to follow the same basic pattern, and their varying radiological appearance is mainly
due to the degree of displacement of the fragments. It may sometimes be shown, for example,
that an untreated Pauwels Type I fracture will conform to Types 11 or III as lateral rotation
of the distal upon the proximal fragment is allowed to increase with buckling or collapse of
the posterior cervical cortex. The Pauwels classification might then appear to be meaningless,

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654 R. S. GARDEN

but, in reality, the direction of the fracture line in the antero-posterior radiograph qfter
reduction, on which this classification is based, provides a reliable indication of the degree of
posterior cortical collapse, and therefore of the limitations of closed reduction. The following
classification, which recognises the significance of the radiographic appearances in the varying
stages of displacement before reduction, is suggested in the hope that it may prove to be of
additional value. Stage I : incomplete fracture (Fig. 6). Stage II : complete fracture without
displacement (Fig. 7). Stage III: complete fracture with partial displacement (Fig. 8). Stage IV:
complete fracture with full displacement (Fig. 9). Intermediary types may sometimes be
recognised between the various stages.
REDUCTION

The criteria of reduction in fractures of the femoral neck have never been strictly defined.
It is not enough simply to rely upon the impression of poor, fair or satisfactory reduction.

FIG. 11
Orthodiagrams illustrating the shape of the femoral head in the frontal radiograph
in undisplaced subcapital fracture (left) and subcapital fracture reduced in
the extreme valgus position (right). Visualisation of the fovea capitis in
this view denotes a moderate degree of valgus deformity, but its bitten-out
appearance in association with a flattened contour of the articular margin as in
the diagram on the right indicates a degree of valgus reposition likely to result in
avascular necrosis.

Innumerable examples of” satisfactory” reduction in the literature show, in fact, that adequate
reposition has by no means been obtained. The almost spherical shape of the femoral head
can be a deceptive factor in the assessment of reduction if its cortical outline alone is considered.
On the other hand, the loss of this circular outline is to be regarded as a danger signal (Fig. 11).
A true interpretation of the relation of the head to the neck may be obtained by visualising
the weight-bearing trabeculae in the two fragments. In the frontal view the medial trabeculae
lie at an angle of approximately 160 degrees with the medial femoral cortex. In the lateral
view the medial and lateral trabeculae converge and decussate upon an axis which runs in a
straight line along the centre of the neck. The normal antero-posterior/ lateral alignment may
therefore be expressed as 160/180. In this way a rough alignment index of reduction is obtained
(Fig. 12). Such factors as distraction, impaction, splintering of the inferior cortex and crushing
of the posterior shell, must remain as disturbing contradictions to every claim of perfect
reduction, and it becomes increasingly obvious that not only must the fracture be reduced-

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LOW-ANGLE FIXATION IN FRACTURES OF THE FEMORAL NECK 655

it must also be stable. Reduction and stability are interdependent, and herein the solution
of the unsolved fracture appears to lie.
In the Stage I subcapital fracture the question of reduction does not arise although the
presence of an extreme valgus position, as will shortly be discussed, may cause some misgiving.
In the Stage II fracture gentle handling should dominate its management if troublesome
displacement is to be avoided.
In the cleanly broken Stage III fracture reduction is easy and stability is assured. The
fragments retain their posterior
retinacular attachment, which Smith (1953) has likened to
the binding of a book, and it seems important to perform reduction at the earliest opportunity
before this binding has been lost. The knee is bent at a right angle and the limb is rotated
medially with no attempt to apply other than steadying traction. This manoeuvre should
be carried out with extreme gentleness and care, forceful manipulation being reserved for

FIG. 12
Antero-posterior and lateral radiographs to show alignment index of 170; 140 in subcapital fracture of
the femur. The degree of reduction shown in the lateral view is unacceptable.

the correction of such isolated deformity as persistent forward angulation, which may
sometimes be countered by sharply applied medial rotation to the affected limb. While the
posterior retinaculum maintains contact between the fragments, traction applied in the long
axis of the limb is communicated through it to the posterior aspect of the head. This results
in anterior angulation with tilting of the capital fragment. In the same way, any fixation
appliance driven
across the fracture site while powerful traction is being applied cannot fail
to cause tilting of the head. Once reduction of the Stage III fracture has been locked by
medial rotation, therefore, compression rather than traction is indicated.
In the Stage IV fracture which has progressed to full displacement the early advantage
of continuity between the fragments has been lost, and many of these fractures will defy even the
most resolute attempts at both closed and open reduction. Careful pre-operative appraisal
of these injuries is advisable in every case, and slipshod radiography should never be accepted.
Good radiographs before or during the operation are not only possible but essential, and
without them many needless pitfalls will be encountered. Good pre-reduction radiographs
will show how frequently this fracture is accompanied by crushing of the thin posterior

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656 R. S. GARDEN

cortical shell of the neck and comminution of the inferior cervical cortex, and will indicate
how difficult reduction may be. Few surgeons can honestly claim to reconstitute the normal
anatomy in these injuries, and it is refreshing to read such forthright observations as that of
Cleveland and Fielding (1954) who, in describing the treatment of 335 fractures of the femoral
neck, state that perfect “ reapposition of the fragments has never been obtained.” Stage IV
fractures form the hard core of subcapital injuries which are particularly resistant to treatment,
and to which the term unsolved
“ fracture “is undoubtedly meant to apply.
For treatment to be successful this inherently unstable fracture must first be stabilised.
This is most easily effected by reduction in the valgus position of lateral rotation deformity
to close the crushing defect in the posterior cortex, but the surgeon should recall Pauwels’s
assertion that the valgus position is nearly always associated with capital necrosis. This
assertion must derive considerable support from the recent observations by Smith (1959),
which have underlined the importance of preserving the normal relationship of the femoral
head in the acetabulum if obliteration of the vessels in the ligamentum teres is to be avoided.
This relationship should therefore be maintained in any attempt to secure stability, which
may possibly be achieved by the insertion of a wedge-shaped graft to bridge the gap in the
posterior cortex, by telescoping the cone-shaped tip of the proximal fragment within the
marrow cavity of the neck, by refashioning the fracture surfaces, by corrective osteotomy or
by the discovery of new methods of fixation. Further research must obviously be concentrated
upon this problem of instability which seems to be the crux of the unsolved fracture. For the
time being, the surgeon can do no more than seek stability with every means at his disposal,
and try to maintain it by the fixation procedure of his choice. For the latter purpose the use
of the low-angle nail has formed the basis of the present inquiry.

OPERATIVE TECHNIQUE

The successful insertion of a low-angle nail depends almost entirely upon the correct
location and obliquity of the entry channel in the lateral femoral cortex. If the nail fits this
hole snugly, as it should, the direction of the hole will dictate the direction of the nail. In a
well reduced and stable fracture with a correctly chosen point of entry the nail is self-locating.
The following technique has been evolved in an attempt to define both the antero-posterior
and lateral proclivity of the entry point. Through a lateral incision a 25-millimetre marker
pin is driven into the outer femoral cortex approximately two and a half inches (63 centimetres)
below the lower border of the greater trochanter. A metal scale graduated in quarter inches
(Fig. 13) is attached to the marker pin and an antero-posterior radiograph is taken. The scale
is then removed and a lateral radiograph is taken. The next and most important stage should
be undertaken by the surgeon himself despite the delay which a change of gown and gloves
entails. A Perspex rule is placed on the antero-posterior film along the line in which the nail
is desired to lie-that is, skirting the calcar and aimed towards the centre rather than the
summit of the head. The point of entry in relation to the marker pin, together with the length
of the nail required, is determined by reference to the shadow of the metal scale on the antero-
posterior film. The lateral radiograph is then consulted, and the entry point in this view is
again defined by reference to the marker pin.
A quarter-inch hole is now drilled precisely at the point of entry, and a cannulated
drill-reamer is used in a hand-chuck to enlarge the hole and convert it into an oblique channel.
The correct degree of obliquity is found by advancing the reamer from time to time until it is
found to slide firmly upwards along the buttress of the calcar. With the reamer still in place,
a guide wire may be inserted to check the accuracy of the entry channel in both views. If
the entry channel is correct, the reamer is removed and a nail of the appropriate length inserted.
Some resistance will at first be felt as the nail firmly negotiates the calcar femorale and inferior
buttress of the neck.

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TABLE I
ANALYSIS OF THIRTY-ONE PATIENTS WITH TROCHANTERIC, BASAL AND MID-CERVICAL FRACTURES.

ALL FRACTURES UNITED

. Period
Period
b f Period in Period of
Al!ment
Sex Type of fracture Wi hospital follow-up
number (years)
(days) (months)
(days)
(days)

I 86 Female Pertrochanteric 12 160180 2 40 16

2 78 Male Pertrochanteric 14 l70t180 1 54 6

3 66 Male Pertrochanteric 4 160/180 1 30 65

4 60 Female Pertrochanteric 4 165180 I 35 64

5 67 Female Pertrochanteric 2 150180 2 33 64

6 79 Female Pertrochanteric 5 160180 10 60 63

7 59 Female lntertrochanteric 3 170180 2 27 62

8 70 Female Basal 4 1 60 1 80 30 20 54

9 79 Female Intertrochanteric I 160180 ‘ 2 11 52

10 69 Female Pertrochanteric 7 160/180 10 57 19

II 71 Female Pertrochanteric 9 155180 5 41 51

12 74 Female Basal 2 160180 3 ‘ 13 10

13 71 Female Intertrochanteric 4 160180 7 50 51

14 62 Female Mid-cervical 7 170170 1 17 50

15 74 Male Pertrochanteric 5 160180 42 94 49

16 58 Male Basal 3 165180 5 14 18

17 80 Female Pertrochanteric 4 170 180 10 47 10

18 71 Female Intertrochanteric 3 170 170 30 59 46

19 78 Female Pertrochanteric I 160/180 1 30 45

20 69 Female lntertrochanteric 2 160 170 2 20 44

21 80 Female Pertrochantcric 1 165/160 4 10 44

22 62 Female lntertrochanteric 3 160 150 - i 69 42


23 70 Female Pertrochanteric 3 155/170 4 32 42

24 68 Male lntertrochanteric 3 160/170 3 38 14

25 84 Female lntertrochanteric I 160’ 165 1 14 39

26 78 Female Basal 3 170165 4 19 33

27 53 Female Basal 4 160180 15 35 33

28 73 Male Pertrochanteric 4 160180 4 74 32

29 82 Female Mid-cervical 5 160180 20 135 21

30 61 Female lntertrochanteric 4 160180 10 60 21

31 54 Male Intertrochanteric 10 160180 20 29 21

VOL. 43 B, NO. 4, NOVEMBER 1961

C
658 R. S. GARDEN

TABLE II
ANALYSIS OF EIGHTY PATIENTS WITH SUBCAPITAL FRACTURES SURVIVING FOR TWELVE MONTHS OR LONGER

I
. Period
Case Age Stage Alignment before Period in Period of
Sex of weight hospital follow-up Result
number (years) fracture operation index bearing (days) (months)

I
(days)
(days) _
32 60 Female 1V 4 185/180 4 34 65 Union*

33 64 Female lV 4 160/180 12 44 29 Union

34 69 Female 1V 5 160/165 6 37 64 Non-union

35 72 Female III 2 190/180 1 17 64 Union*

36 74 Female lV 1 160/165 6 24 63 Non-union

37 74 Female 1I 2 170/175 5 25 63 Union

38 82 Female I 1 170/165 3 13 13 Union


39 86 Female I 4 170/170 3 22 12 Union

40 67 Female Ill 4 160/170 I 22 61 Union

41 66 Female 111 2 200/180 3 44 60 Union*

42 75 Female lv 6 175/150 7 22 57 Non-union

43 52 Female III 5 190/175 1 16 56 Union*

44 60 Female IV 4 150/140 2 19 56 Non-union

45 66 Female lv i 160/150 - 62 56 Non-union

46 75 Female 1V 5 160/180 2 17 55 Union

47 57 Female 111 1 200/150 6 27 55 Union*


48 62 Female IV 1 160/180 1 24 ‘ 51 Union

49 72 Female I 10 170/180 1 21 51 Union

50 81 Female 111 1 185/170 2 27 50 Union*

51 47 Female IV 3 100/140 7 13 50 Non-union

52 90 Female 1 1 180/170 3 20 14 Union

53 73 Female lv 2 170/160 2 30 14 Union

54 65 Female III I 180/170 1 17 49 Union

55 74 Female I 4 180/180 1 57 46 Union

56 70 Female IV 3 155/150 7 49 43 Non-union

57 86 Female IV 4 165/180 1 25 48 Union

58 67 Female III 2 165/180 3 26 23 Union

59 69 Female III 5 160/180 - 35 47 Non-union

60 75 Female Ill I 170/170 3 38 45 Union

61 67 Female III 2 160/170 10 20 45 Union*

62 67 Male IV 2 180/170 5 40 45 Union

63 64 Female IV I 200/180 1 15 45 Union*

* Avascular necrosis.

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TABLE Il-continued

ANALYSIS OF EIGHTY PATIENTS WITH SUBCAPITAL FRACTURES SURVIVING FOR TWELVE MONTHS OR LONGER

Period
Period
Case A ge
Stage before Period in Period of
before Alignment
Sex of weight hospital follow-up Result
number (years) operation index
fracture bearing (days) (months)
(days)
(days)

64 46 Male IV 1 180/170 I 21 45 Union

65 50 Female II 9 180170 2 20 44 Union

66 69 Female IV 2 180130 21 30 15 Non-union

67 56 Female IV 3 170140 5 32 42 Non-union

68 67 Female IV 2 180/140 14 18 42 Non-union

69 69 Female III 4 160180 5 40 15 Union

70 69 Female III 7 190/160 60 39 Union*


71 65 Female II 10 170/180 2 28 38 Union
72 74 Female IV 2 170:170 50 38 Union
73 62 Male III II 180165 3 28 38 Union

74 58 Female II 6 165160 9 55 37 Union


75 70 Female i ill 5 150160 - 30 37 Non-union

76 78 Female III 6 160/180 7 25 34 Union

77 66 Female III 2 160180 3 22 33 Union


78 63 Female III 2 200/180 2 22 31 Union*
79 40 Male II 2 160180 2 17 30 Union

80 51 Male IV 5 160/160 3 15 30 Union

81 56 Male II 2 180180 I 12 28 Union

82 76 Female Ill 5 160180 8 Il 28 Union

83 52 Female IV 3 180/150 15 21 27 Non-union

84 63 Female II 3 160/180 3 48 27 Unionf

85 67 Female 1 7 160/180 2 15 26 Uniont

86 70 Female 1V 2 160/160 6 9 26 Union

87 83 Female III 2 180/180 6 16 25 Union

88 74 Female IV 9 170/180 8 58 24 Non-union

89 66 Female I 3 160/180 6 20 23 Union


90 64 Female III 2 170/180 5 14 23 Union
91 66 Male II 3 160/180 5 26 22 Union

92 71 Male II 2 160/180 18 54 21 Union


93 59 Female Ill 3 160/155 4 38 19 Uniont

94 75 Female IV 1 160/160 7 30 19 Uniont

95 72 Female III 2 160/170 6 14 18 Union

* Avascular necrosis.
t Low-angle screw.

VOL. 43 B, NO. 4, NOVEMBER 1961


660 R. S. GARDEN

TABLE Il-continued
ANALYSIS OF EIGHTY PATIENTS WITH SUBCAPITAL FRACTURES SURVIVING FOR TWELVE MONTHS OR LONGER

. Period
Stage Alignment before Period in Period of
Case Age
Sex of weight hospital follow-up Result
number (years) operation index
fracture bearing (days) (months)
(days)
(days)

96 60 Male III 4 160/180 5 20 : 18 Uniont

97 86 Female IV 3 160/180 7 21 17 Union


:

98 72 Female
. III 6 160/180 5 30 16 Union

99 74 Female 111 2 160/180 8 27 16 Uniont

100 34 Male 111 2 160/180 5 28 16 Uniont

101 51 Male II 1 160/180 2 15 16 Uniont

102 51 Female IV 4 165/180 2 18 15 Union

103 70 Female I 5 170/180 3 17 15 Union

104 38 Male III 2 165/160 10 17 15 Union

105 70 Female III 4 160/180 4 46 15 Union

106 64 Female III 4 195/170 14 35 14 Union*

107 62 Female IV 1 175/155 3 18 14 Non-union

108 56 Female I 1 160/180 1 25 13 Union


109 39 Male 11 5 160/180 2 16 13 : Uniont

110 72 Female 1V 2 170/160 6 49 13 Uniont

III 73 Female IV 6 170/180 17 39 12 Uniont

* Avascular necrosis. t Low-angle screw.

This brief description of the operative technique is by no means intended to convey the
impression that low-angle nailing is always a straightforward procedure. On the contrary, it
is often a most difficult undertaking, and only by meticulous attention to detail can it be
expected to succeed.

MATERIAL
The low-angle KUntscher nail is unsuitable for the treatment of fractures involving the
lesser trochanter with fracture of the calcar femorale at this level. Without the support of the
calcar the nail inclines inwards until it lies against the medial femoral cortex below the line
of fracture and varus deformity occurs. During the past five and a half years 450 patients
with all types of fractures of the femoral neck have been admitted to the Preston Royal
Infirmary. One hundred and fifty-nine of these fractures were situated above the level of the
lesser trochanter, and were considered suitable for low-angle fixation. Full weight bearing
was encouraged whenever possible after operation, and many patients were walking unaided
and discharged home within a few weeks of their injury.

RESULTS
Thirty-one patients who sustained mid-cervical, basal, intertrochanteric or high per-
trochanteric fractures, and who survived for at least six months, all obtained full union
(Table I). These fractures unite freely with any modern method oftreatment, but consolidation

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LOW-ANGLE FIXATION IN FRACTURES OF THE FEMORAL NECK 661

is undoubtedly hastened by early weight bearing. In these particular injuries, therefore, the
advantages of low-angle fixation are self-evident.
The assessment of union in subcapital fractures within twelve months of the injury is
generally considered unwise. Of eighty patients in this series who were under observation
for twelve months or longer sixty-five (81 per cent) showed full radiological union (Table II).

TABLE III
SUBCAPITAL FRACTURES:

RELATION OF UNION TO STAGE OF FRACTURE

Stage United Ununited Percentage

9 9 - 100

II II Ii - 100

III 30 28 2 93
IV 30 17 13 :

Totals : 80 65 : 15 81

On closer analysis the problems of union were seen to arise almost exclusively in the Stage IV
fractures, of which only 57 per cent united (Table III). It is therefore misleading to present
the results of treatment in subcapital fractures as an overall percentage, and the value of the
low-angle, or any other, fixation procedure should be judged principally by the results of its
use in fully displaced Stage IV injuries.
Examination of the relationship between reduction and union shows that non-union in
this series was largely confined to those cases in which an alignment index of less than 155
was accepted in either the antero-posterior or lateral view. It is clear that poor reduction is
almost synonymous with non-union, and good reduction greatly improves the chances of
success. Low-angle fixation after imperfect reduction may then be regarded as a worthless
procedure.

COMPLICATIONS
Movement of the nail-The K#{252}ntscher clover-leaf type of nail has the advantage of strength
and lightness, but cannot always be relied upon to remain in place. In several instances the
nail intruded into the hip joint or extruded sufficiently to allow slipping at the fracture site.
For this reason a low-angle screw with a short self-tapping thread has been devised (Fig. 13, D).
The capital fragment alone is held by the screw, and its shank can extrude as need be through
the sleeve formed by the entry channel in the lateral femoral cortex. In the stable fracture
impaction is ensured in this way as absorption or settling at the fracture site occurs. It is
now believed, however, that in the fully displaced unstable fracture such absorption “ or
settling” is often mistaken for an increasing collapse of the posterior cortex with the return
of anterior angulation and breakdown of reduction. As a consequence, the fallacy of overall
compression in the treatment of displaced subcapital fractures has been recognised. The
screw, now under trial, has therefore been provided with a longer thread to engage both
fragments, and, when positioned posteriorly, to maintain distraction at the posterior aspect
of the fracture (Fig. 13, E). Since the capital fragment is mobile, distraction posteriorly
results in compression anteriorly. In this sense, distraction really implies restoration of the
normal compressive function of the posterior cervical cortex.
Avascular necrosis-No discussion of femoral neck fractures can escape the question of
avascular necrosis, especially one in which early weight bearing is being advised. According
to d’Aubign#{233} (1958) 50 per cent of all subcapital fractures develop avascular necrosis. In this

VOL. 43 B, NO. 4, NOVEMBER 1961


662 R. S. GARDEN

series complete collapse and disappearance of the head was seen once, and well defined
avascular change with localised collapse was seen in ten fractures which united.
Even with severe disruption of the retinacular vessels, the foveal artery, as Tucker ( I 949)
has shown, remains as a source of nutrition in most elderly patients. In this connection it is
of the utmost significance to record that avascular necrosis followed union in every case in
which an alignment index greater than 180 in the frontal view-in other words an extreme
valgus position-was accepted at reduction in this series. It is equally significant that this
complication was encountered only once when the alignment index was less than I 80, and this
in a case where the nail entered the hipjoint. Both in regard to union and to avascular necrosis,
therefore, the safe limit of malposition appears to lie within the narrow alignment index range
of I 55/I 80 in the antero-posterior and 180/1 55 in the lateral radiograph.

L..I

H1IJ

FIG. 13
A-Metal measuring scale with marker pin. B-Perspex rule. C-
Cannulated drill-reamer. D-Cannulated low-angle screw with short
self-tapping thread. E-Cannulated low-angle screw with extended
self-tapping thread. F-Cannulated Allan key driver.

Degenerative arthritis-In regard to the late results in the series under examination it is
expected that even the restricted limits of malposition defined above may prove to be over
generous. Failure to achieve perfect reduction will at the same time fail to restore the critical
relationship of the femoral head in the acetabulum with which it is congruous only in the
position of weight bearing (Walmsley 1928). The constant apposition of dissimilar articular
surfaces, which will then ensue, must inevitably lead to degenerative arthritic changes.

SUMMARY AND CONCLUSIONS


The successful management of femoral neck fractures is obviously based upon many
factors. The forces acting upon the proximal end of the femur are believed to be mainly
compressive in nature, and the low-angle nail by stabilising the fully reduced fracture in the
line of these forces is held to allow weight bearing to take place. Low-angle nailing is believed
to offer many advantages over conventional methods of treatment but only in the presence
of stability. Stable reduction is the essential preliminary to any form of treatment, and low-
angle fixation with early weight bearing in the absence of stability is regarded as futile.

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LOW-ANGLE FIXATION IN FRACTURES OF THE FEMORAL NECK 663

It is suggested that those subcapital separations which follow trivial injury may originate
as stress fractures accompanying the process of bone remodelling in the aged, and that many
of these fractures may remain unrecognised and heal spontaneously. With rare exceptions,
subcapital fractures are regarded as being of the same essential pattern, and their varying
radiological appearance is considered to be due to the different degrees of displacement to
which they have been subjected. A new classification based on this premise has been suggested.
In a series of eighty subcapital fractures the incidence of avascular necrosis was not
adversely affected by early weight bearing, but reduction in the extreme valgus position was
invariably followed by this disaster. This is probably also true of any malposition in extreme
rotation which must stretch and obliterate the vessels in the ligamentum teres.
A rough alignment index of reduction was found to provide an almost infallible guide
to the prognosis both in regard to union and to avascular change. It may therefore be possible
to base prognosis on the quality of reduction before the fixation appliance has been inserted.
The unsatisfactory results in those cases apparently destined to non-union or avascular
necrosis may then be avoided by alternative means of treatment at an early stage. Whether
this will prove to be true must depend upon a much longer experience of low-angle fixation,
and, in common with almost every communication on this subject, premature publication
must largely offset the value of the present findings.

I am much indebted to Mr N. A. G. Covell and to my registrars Mr F. F. Silk and Mr D. G. Wray for their
encouragement, assistance and invaluable criticism in the work on which this inquiry has been based.

REFERENCES

D’AUBIGNE, R. Merle (1958): Pseudarthroses du col du femur. Presse M#{233}dicale,66, 813.


BACKMAN, Stig (1957): The Proximal End of the Femur. Acta Radiologica, Supplementum 146.
BRITTAIN, H. A. (1942): The Low Nail. British Medical Journal, i, 463.
BURNS, B. H., and YOUNG, R. H. (1944): Early Movement in the Treatment of Closed Fractures. Lancet, i, 723.
CLEVELAND, M., and FIELDING, W. J. (1954): A Continuing End-result Study of Intracapsular Fracture of the
Neck of the Femur. Journal of Bone and Joint Surgery, 36-A, 1,023.
DICKSON, J. A. (1953): The “ Unsolved “ Fracture. Journal ofBone andJoint Surgery, 35-A, 805.
FARKAS, A., WILSON, M. J., and HAYNER, J. C. (1948): An Anatomical Study of the Mechanics, Pathology,
and Healing of Fracture of the Femoral Neck. Journal of Bone and Joint Surgery, 30-A, 53.
GARDEN, R. S. (1961) : The Structure and Function of the Proximal End of the Femur. Journal of Bone and
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GOD0Y MOREIRA, F. E., and CAMARGO, F. P. de (1957): Contribui#{231}#{224}o
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KING, T. (1939): The Closed Operation for Intracapsular Fracture of the Neck of the Femur. British Journal
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KUNTSCHER, G. (1953): Die vollautomatische Schenkelhalsnagelung. Zeitschrzft f#{252}rOrthopddie und ihre
Grenzgebiete, 84, 17.
LINTON, Per. (1949): Types of Displacement in Fractures of the Femoral Neck. Journal of Bone and Joint
Surgery, 31-B, 184.
PATRICK, J. (1949): Intracapsular Fractures of the Femur Treated with a Combined Smith-Petersen Nail and
Fibular Graft. Journal of Bone and31-A, 67.
Joint Surgery,
PAUWELS, F. (1935): Der Schenkelhalsbruch. Em mechanisches Problem. Stuttgart: Ferdinand Enke.
SMITH, F. B. (1959): Effects of Rotatory and Valgus Malpositions on Blood Supply to the Femoral Head.
Journal of Bone and Joint Surgery, 41-A, 800.
SMITH, L. D. (1953): Hip Fractures. Journal of Bone and Joint Surgery, 35-A, 367.
TUCKER, F. R. (1949): Arterial Supply to the Femoral Head and its Clinical Importance. Journal of Bone and
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VOL. 43 B, NO. 4, NOVEMBER 1961

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